2 Different Death PathwaysThree paths to death:Death occurs without any warning.AccidentSudden, fatal, age-related event (heart attack, stroke)People decline steadily as they approach death.Dx with a fatal disease, possibly in the advanced stagesPeople have an erratic course; fatal disease takes years or decades with ups and downs.Most common dying patternTypically helped by medical technology

3 History of DyingDeath as a natural part of life (eighteenth and nineteenth century)No medicine − People died quickly of infectious diseases.Dying was familiar − It was routine event at every stage of life and a typical part of the community.Later, due to fears of disease, death became more removed from the community.Death is vigorously addressed by doctors (early twentieth century)Modern medicine conquers infectious diseases, moving death to the end of the lifespan.Dying moved to hospitals, far from view.Result was that dying is a strange, frightening “health-care-managed” event.Death awareness movement (late 1960s)Talking about death becomes acceptable.Thanatology (study of death and dying) classes became the rage on university campuses.Doctors were more willing to talk about cancer.

4 Cultural VariationsThe Hmong – Asian population that migrated to North America after Vietnam WarBelieved dying could “unlock the gate of evil spirits”A diagnosis of terminal illness is not discussed.When death becomes imminent, family gathers around loved one, dressing ill person in traditional burial garment (black robe or suit).After death, the deceased is washed and groomed, preparing to be viewed.If death occurs in a hospital, family is allowed the opportunity to mourn person before body is transported to morgue.

5 Kϋbler-Ross – Stages of DyingElizabeth Kϋbler-Ross published best seller On Death and Dying in 1969.The book was based on research she had conducted by interviewing dying patients about their feelings.Developed stage theory of dyingIn her research, Kϋbler-Ross found:Open communication is important. Those who are diagnosed with a terminal illness are often realized to discuss their condition.Dying people pass through five emotional stages.

6 Kϋbler-Ross’s five emotions regarding death and dyingDenialPerson may believe the diagnosis was a mistake.May try to get several “second opinions”AngerPerson may lash out, maybe even at the doctor.BargainingPerson may plead for more time, often to God.Makes promises to be “good” if death is delayedDepressionPerson becomes distraught by the thought of his or her death.AcceptanceFinal stage where the person begins to accept his or her fate.

7 Problems with Kϋbler-Ross’s theoryWhile Kϋbler-Ross’s theory helped people reconsider the approach to death and dying, it was seen as rigid and simplistic. Therefore, it may not be accurate for all people.Problems with theory:Not all terminally ill patients want to discuss their situation.Do not assume that every terminally ill patient will want to discuss his or her condition.Person may want to focus on quality of personal relationships as opposed to such a painful issue.Not every culture feels it is appropriate to openly discuss death.Western culture says knowing is important, but the amount of information that is shared differs.Not every person passes through distinctive stages adjusting to death.Feelings may be missed or minimized as “a phase.”

8 The More Realistic View: Differing EmotionsDying people experience many emotions (but not in predictable stages).Some experience a state called middle knowledge – terminally ill people know they are dying but can not fully grasp it emotionally.Hope is often the main emotion (I can beat this thing!) until the very end.This is contradictory to Kϋbler-Ross’s final stage of “acceptance.”Some are energized and feel more alive, often reevaluating life goals.The elderly typically report no fear of death, although they are afraid of the pain of dying.Off-time deaths (such as in youth) are particularly painful for the person and survivors.Randi Pausch

9 Death of a childA child’s death outweighs any other loss. It is more devastating than any other life event.What can help parents deal with the death?Discussing death with a child can help parent avoid any regrets.Sharing in the hands-on care during the final days can be rewarding.Feeling health-care providers are caring and supportive can help relieve some of the pain.

10 In search of a “good” deathGuidelines for a good death:Minimize physical distress to be free of possible debilitating pain.Maximize psychological security, and reduce fear and anxiety, thus feeling in control of death.Enhance relationships and be close as possible to loved ones.Foster spirituality and have a sense of integrity and purpose in life.

12 Problems with the Health-Care System and DyingDying trajectory – how hospital personnel make predictions about what pattern the person’s dying was likely to followExpected swift death – death is imminent with no chance of survivalExpected lingering while dying – advanced stages of terminal illness with a slow declineEntry−re-entry – pattern of admittance to hospital, stabilization, then discharge until deathProblem is that dying schedules can not be predicted.Mistakes made regarding dying trajectory can hasten death.

13 Problems with health care and dyingShort-term health carePeople do not spend weeks or months in the hospital but enter near death.Thus, relationships are not formed with health-care professionals who may be less understanding.Disagreements among health-care providersPhysicians have the final decision about treatment.However, nurses may have relationship with patients, but feel advocating for the dying patient may have consequences.A multicultural societyRaises risk of miscommunication between families of the dying person and hospital staffAdvanced medical technologyThese technologies allow death to be prolonged even when the body is shutting down.

14 Understanding Palliative CarePalliative Care – any strategy designed not to cure illness but to promote a dignified dying, which includes:Educating health-care professionals on end-of-life careHas become mainstream in medical training programsOne problem is the frequency, partly because they contradict the medical goal to save lives.Palliative care service − specific unit devoted to providing high-quality end-of-life carePatients can still receive cure-oriented interventions.Main intervention is “comfort care”Can be cost-effective

15 The Hospice MovementHospice Movement – a movement, which has become wide-spread in recent decades, focused on providing palliative care to dying patients outside of hospitals and especially on giving families the support they need to care for the terminally ill at home.Has the same philosophy as the natural childbirth movement – like birth, death is a human eventTakes it out of the hands of medicineGained momentum in the early 1970sMost often today, hospice involves multi-disciplinary teams that come into the person’s home to help family cope.

16 Barriers to Hospice CarePeople are reluctant to give up hope and admit that death is imminent.May diverge from cultural norms in which belief is not to discuss death.Person needs an involved family committed to provide the intense care involved with dying at home.Physicians may also be reluctant to tell families that their loved one is dying.Most people in hospice enter when death is imminent.

17 Problems with Dying at HomePatient:No privacy with intimate needs cared for by family (bathing, dress, etc.)Can be burdensome to family membersFamily:Must be on call 24/7 to provide careMay have to give up other responsibilities, including maintaining work outside the homeCan cause huge financial strain

19 Taking control of deathTwo strategies for taking control of a person’s ability to achieve a “good death.”Advance DirectivesEuthanasia

20 Advance DirectivesAdvance Directives − written document spelling out instructions with regard to life-prolonging treatment if the person becomes irretrievably ill and cannot communicate his or her wishesFour types:Living willsDurable power of attorney for health careDo Not Resuscitate Orders (DNR)Do Not Hospitalize Orders (DNH)

21 Types of Advance DirectivesLiving will − spells out a person’s wishes for life-sustaining treatment in case he or she becomes permanently incapacitated and unable to communicateDurable power of attorney for health care – person designates a specific surrogate to make health-care decisions if he or she becomes incapacitated and unable to make his or her wishes knownDo Not Resuscitate Orders (DNR) – advanced directive completed by surrogates (typically doctors in consultation with the family) for an impaired person, specifying that no efforts will be made to revive him or her in case of cardiac arrestDo Not Hospitalize Orders (DNH) – advanced directive put into the charts of impaired nursing home residents, specifying that in a medical crisis they should not be transferred to a hospital for emergency care

22 Euthanasia Two important distinctions:Passive euthanasia – withdrawing potentially life-saving interventions (e.g., feeding tubes)These instructions are typically designed in advance directives, therefore it is acceptable.Active euthanasia – taking action to help the person dieIllegal everywhere but Belgium, the Netherlands, and Luxembourg.Physician-assisted suicide – a type of active euthanasia in which a physician prescribes a lethal medication to a terminally ill person who wants to die

23 Issues with Active EuthanasiaSurveys indicate support for “restricted” active euthanasia.If person is terminally ill and in painHowever, there is resistance to making it a legal practice.Legalizing euthanasia may lead to:Violating the religious injunction against suicide – belief that only God can give or take a lifeInvoluntary euthanasia – doctors terminating treatment for people who do not want to diePerson might be pressured into deciding to die by unscrupulous family members.Person might be seriously depressed, and would not want to die if the depression were treated.

24 “Slippery Slope” IssuesDaniel Callahan, prominent biomedical ethicist, argues for age-based rationing of care.Defined as the idea that society should not use expensive life-sustaining technologies on people in their old-old yearsTwo arguments:After a person has lived out a natural lifespan, medical care should no longer be oriented to resisting death.The existence of medical technologies capable of extending the lives of elderly persons who have lived out a natural lifespan creates no presumption that the technologies must be used for that purpose.Focus on preventing premature death.